PROTECTING THE POOR AGAINST HEALTH SHOCKS Gerald Bloom and Henry Lucas Institute of Development Studies Meeting the needs of the very poorest in service delivery BRAC, Rajendrapur 3-5 December 2006

TYPES OF ILLNESS SHOCKS Intensity – minor and major illness (degree of debility and cost of treatment) Intensity – minor and major illness (degree of debility and cost of treatment) Duration and/or frequency (repeated shocks and progressive chronic disease –NCDs & HIV/AIDS) Duration and/or frequency (repeated shocks and progressive chronic disease –NCDs & HIV/AIDS) Covariance (endemic diseases, epidemics, relationship to other shocks) Covariance (endemic diseases, epidemics, relationship to other shocks) Resilience and poverty-illness traps

RESPONSE TO SHOCKS Prevention (public health, preventive programmes, response to crisis) Prevention (public health, preventive programmes, response to crisis) Mitigation (improve basic services, subsidise access to care, improve unorganised services through regulation and information) Mitigation (improve basic services, subsidise access to care, improve unorganised services through regulation and information) Coping (support the ill, post-illness recovery of households, rebuild communities after major shocks) Coping (support the ill, post-illness recovery of households, rebuild communities after major shocks)

INSTITUTIONAL REALITIES Segmented and pluralistic health systems and social sector Segmented and pluralistic health systems and social sector Importance of household and community institutional arrangements Importance of household and community institutional arrangements Balance between general social protection and earmarked health support Balance between general social protection and earmarked health support Importance of local political economy and differential impact of interventions Importance of local political economy and differential impact of interventions

BALANCE OF APPROACHES Rules-based universal coverage Rules-based universal coverage Safety net and special programmes for poor and vulnerable Safety net and special programmes for poor and vulnerable Discretionary/charitable support Discretionary/charitable support Community and family arrangements Community and family arrangements

UNIVERSAL COVERAGE ADVANTAGES: rules-based, predicable, strong entitlement, creates possibility of measures to improve supply-side ADVANTAGES: rules-based, predicable, strong entitlement, creates possibility of measures to improve supply-side PROBLEMS: hard to define benefit, may favour better off or those living near hospitals, limited financial capacity, may neglect the special problems of the very poor and those excluded because of geography and other factors PROBLEMS: hard to define benefit, may favour better off or those living near hospitals, limited financial capacity, may neglect the special problems of the very poor and those excluded because of geography and other factors

TARGETED PROGRAMMES AND SAFETY NET ADVANTAGES: allocates resources to very poor, special service package, efficient use of scarce resources ADVANTAGES: allocates resources to very poor, special service package, efficient use of scarce resources PROBLEMS: limited resources, may leave beneficiaries trapped in poverty, may not reach the poorest, stigmatises beneficiaries, weak entitlement that depends on resource availability, limited political support PROBLEMS: limited resources, may leave beneficiaries trapped in poverty, may not reach the poorest, stigmatises beneficiaries, weak entitlement that depends on resource availability, limited political support

DISCRETIONARY BENEFITS ADVANTAGES: resources used for poor people with big problems, flexible, builds on social concern, less leakage ADVANTAGES: resources used for poor people with big problems, flexible, builds on social concern, less leakage PROBLEMS: unreliable and dependent on fund- raising, can unfairly target “deserving” poor or those who capture public interest, stigma, little voice for beneficiaries, can reinforce exclusion PROBLEMS: unreliable and dependent on fund- raising, can unfairly target “deserving” poor or those who capture public interest, stigma, little voice for beneficiaries, can reinforce exclusion

INFORMAL ARRANGEMENTS ADVANTAGES: well-established social networks, responds to immediate human feelings, high levels of trust and good targeting, no need for complex institutions ADVANTAGES: well-established social networks, responds to immediate human feelings, high levels of trust and good targeting, no need for complex institutions PROBLEMS: little support for people without large families or in disadvantaged communities or social groups, limited financial capacity to deal with major problems, may stigmatise recipients and leave them in a dependent position PROBLEMS: little support for people without large families or in disadvantaged communities or social groups, limited financial capacity to deal with major problems, may stigmatise recipients and leave them in a dependent position

BALANCE OF APPROACHES Level of economic development Level of economic development Capacity to support complex, rules-based institutions Capacity to support complex, rules-based institutions Degree of inequality and number of very poor Degree of inequality and number of very poor Supply-side inequalities Supply-side inequalities

RESEARCH CONSORTIA POVILL: impact of major illness on poor households and government initiatives to mitigate the impact and support household coping in China, Cambodia and Lao PDR POVILL: impact of major illness on poor households and government initiatives to mitigate the impact and support household coping in China, Cambodia and Lao PDR FUTURE HEALTH SYSTEMS RPC: strategies for increasing access and reducing the impact of major health shocks FUTURE HEALTH SYSTEMS RPC: strategies for increasing access and reducing the impact of major health shocks

ISSUES FOR PANEL Balance of approaches in different development contexts Balance of approaches in different development contexts Roles of state, non-state institutions, charities and “informal” faith-based, community and family arrangements in different contexts Roles of state, non-state institutions, charities and “informal” faith-based, community and family arrangements in different contexts Sequencing, path dependency and the politics of institutional strengthening and building rules-based entitlements (balance between meeting short-term needs and managing social transformation) Sequencing, path dependency and the politics of institutional strengthening and building rules-based entitlements (balance between meeting short-term needs and managing social transformation)